Army 2009 Field Manual FM 6-22.5

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FM 6-22.5March 2009

COMBAT AND OPERATIONAL STRESS CONTROLMANUAL FOR LEADERS AND SOLDIERS

DISTRIBUTION RESTRICTION. Approved for public release; distribution is unlimited.

Headquarters, Department of the Army


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This publication is available at

Army Knowledge Online (www.us.army.mil) and

General Dennis J. Reimer Training and DoctrineDigital Library at (www.train.army.mil).


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*FM 6-22.5

Distribution Restriction: Approved for public release; distribution is unlimited.

*This publication supersedes FM 6-22.5 dated 23 June 2000 and FM 22-51 dated 29 September 1994.

18 March 2009 FM 6-22.5 i

Field Manual

No. 6-22.5

Headquarters

Department of the Army

Washington, DC, 18 March 2009

Combat and Operational Stress Control Manualfor Leaders and Soldiers

Contents

Page

PREFACE .............................................................................................................. v INTRODUCTION ................................................................................................... vi

Chapter 1 Combat and Operational Stress Reaction Ident ifi cation .............................. 1-1

Section I — Introduction and Historical Perspect ive .................................... 1-1 Introduction ......................................................................................................... 1-1 Historical Perspective ......................................................................................... 1-1

Section II — Reactions to Combat and Operational Stress ......................... 1-2 Stress Behaviors in Full Spectrum Operations .................................................. 1-2

Section III — Forms of Combat and Operational Stress .............................. 1-3 Potentially Traumatic Event ................................................................................ 1-3

Section IV — Observing and Recognizing Common Reactions toCombat and Operational St ress ...................................................................... 1-6 Combat and Operational Stress Reactions May Affect Soldiers in all Types ofMilitary Operations .............................................................................................. 1-6

Section V — Role of the Unit Ministry Team................................................ 1-11 Unit Ministry Team Support .............................................................................. 1-11

Section VI ― Role of Unit Behavioral Health Assets .................................. 1-12 Mental Health Sections .................................................................................... 1-12

Section VII — Referrals of Soldiers Experiencing Combat andOperational Stress Reaction and/or Other Stress-Related Disorders ...... 1-14 Recognize Severe Stress Reactions ................................................................ 1-14

Chapter 2 Combat and Operational Stress Prevention, Management, and Contro l ... 2-1 Section I — Introduction and Factors Which Influence Combat andOperational Stress and Leader Act ions ......................................................... 2-1 Introduction ......................................................................................................... 2-1


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Combat and Operational Stress Control Risk Factors or Stressors andPreventive Measures or Leader Actions ............................................................. 2-1

Section II — Preventing and Managing Combat and Operational Stress ... 2-6 Cohesion and Morale .......................................................................................... 2-6

Section III — Stress-Reduction Techniques for Leaders.............................. 2-7

Preventive Actions .............................................................................................. 2-7 Section IV — Performance Degradation Prevention Measures ................... 2-9 Effectively Sustain Performance ......................................................................... 2-9

Sect ion V — Effect ive Leadership ................................................................. 2-11 Leaders are Competent and Reliable ............................................................... 2-11

Section VI — Managing Soldiers In Distress ............................................... 2-12 Guidance and Tools for Leaders ...................................................................... 2-12 Leader Actions to Manage and Prevent Deployment Distress ......................... 2-15 Family Readiness Group .................................................................................. 2-16

Section VII — Traumatic Event Management, Cool-Down Meetings, andLeader-Led After-Action Debriefing .............................................................. 2-21 Traumatic Event Management .......................................................................... 2-21 Cool-Down Meetings ......................................................................................... 2-23 Leader-Led After-Action Debriefing .................................................................. 2-23

Chapter 3 Command Leadership Actions and Combat and Operational Stress ControlPrograms ........................................................................................................... 3-1

Section I — Unit Behavioral Health Needs Assessment Survey .................. 3-1 Introduction ......................................................................................................... 3-1 Using an Assessment Tool ................................................................................. 3-1

Section II — Effective Combat and Operational Stress Control Program .. 3-2 Minimize Stress ................................................................................................... 3-2 Mobilization ......................................................................................................... 3-2 Deployment ......................................................................................................... 3-5

Section III — Combat and Operational Stress Control ResiliencyTraining .............................................................................................................. 3-8 Battlemind Training—Building Soldier Resiliency ............................................... 3-8

Section IV — Battlemind Warrior Resiliency and Combat andOperational Stress Control .............................................................................. 3-9 Peer-Support Program ........................................................................................ 3-9

Section V — Leadership Actions and Interventions for Combat andOperational Stress React ions ........................................................................ 3-10 Leader Intervention ........................................................................................... 3-10

Section VI — Combat and Operational Stress Reaction ............................. 3-11 Guidelines for the Management of Combat and Operational Stress Reaction 3-11

Section VII — Safety Considerations ............................................................ 3-13 Soldier and Unit Safety Comes First ................................................................. 3-13

Chapter 4 Sleep Deprivation .............................................................................................. 4-1

Section I — Introduction and Sleeping in the Operational Environment .... 4-1 Introduction ......................................................................................................... 4-1 Sleeping Environment Information and Related Factors .................................... 4-1


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Section II — Maintaining Performance During SustainedOperations/Continuous Operations ............................................................... 4-3

Countermeasures to Maintain Performance ...................................................... 4-3

Section III — Understanding the Effects and Misconceptions o f SleepLoss and Sleep Loss Alternatives .................................................................. 4-5

Specific Sleep Loss Effects ................................................................................ 4-5

Chapter 5 Potential ly Life-Threatening Thoughts and Behaviors ................................. 5-1

Section I — Introduction and Threat of Suic ide ............................................ 5-1

Introduction ......................................................................................................... 5-1

Threat of Suicide and Potential Suicide Risk ..................................................... 5-1

Section II — Threat of Violence to Others and the Risk of UnlawfulBehaviors .......................................................................................................... 5-2

Dangerousness to Others .................................................................................. 5-2

Appendix A Mild Traumatic Brain Injury and Posttraumatic Stress Disorder ................ A-1

Appendix B Behavioral and Personal ity Disorders ........................................................... B-1

GLOSSARY .......................................................................................... Glossary-1

REFERENCES .................................................................................. References-1

INDEX .......................................................................................................... Index-1

Figure

Figure 1-1. Combat and operational stress effect model ...................................................... 1-3

Tables

Table 1-1. Combat stressors and operational stressors ...................................................... 1-2

Table 1-2. Adaptive stress reactions .................................................................................... 1-4

Table 1-3. Mild stress reactions ........................................................................................... 1-7

Table 1-4. Severe stress reactions ...................................................................................... 1-7

Table 2-1. Combat and operational stress control risk factors or stressors andpreventive measures or leader actions ............................................................... 2-1

Table 2-2. Environmental and physical risk factors or stressors and preventive

measures or leader actions ................................................................................ 2-2Table 2-3. Unit casualties and other potentially traumatic event risk factors or

stressors and preventive measures or leader actions ........................................ 2-2

Table 2-4. Adjustment and transitional issues (predeployment) risk factors orstressors and preventive measures or leader actions ........................................ 2-3

Table 2-5. New Soldier integration risk factors or stressors and preventivemeasures or leader actions ................................................................................ 2-3


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Table 2-6. Perceived threat or actual use of chemical, biological, radiological, andnuclear weapons risk factors or stressors and preventive measures orleader actions ..................................................................................................... 2-4

Table 2-7. Home front issues risk factors or stressors and preventive measures orleader actions ..................................................................................................... 2-4

Table 2-8. Loss of confidence, lack of cohesion, and decreased morale risk factorsor stressors and preventive measures or leader actions........................... ........ 2-5

Table 2-9. Adjustment and transitional issues (postdeployment) risk factors orstressors and preventive measures or leader actions ....................................... 2-6

Table 4-1. Basic sleep scheduling factors ........................................................................... 4-2

Table 4-2. Basic sleep environment and related factors ..................................................... 4-3

Table 4-3. Using caffeine under various conditions of sleep deprivation ............................ 4-4

Table A-1. Healing and management of symptoms ............................................................. A-2

Table A-2. Symptoms that may be experienced from posttraumatic stress disorders ........ A-3


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Introduction

Current combat operations in support of the war on terrorism (WOT) and US Army transformation have

resulted in an institutional shift in how leaders view, approach, and manage the effects of combat and

operational stress. Combat and operational stress control has always been a commander’s program. To be

successful, commanders must fully understand and appreciate the magnitude of a potentially traumatic

event (PTE) as it affects exposed organizations and individuals. It is a harsh reality that combat and

operational stress affects everyone engaged in full spectrum operations. No Soldier or Family member will

remain unchanged. It should be viewed as a continuum of possible outcomes that each person will

experience with a range from positive growth behaviors to negative and sometimes disruptive reactions.

Effective leadership shapes the experience that they and their Soldiers go through in an effort to

successfully transition units and individuals, build resilience and promote posttraumatic growth (PTG), or

increased functioning and positive change after enduring trauma. Combat and operational stress control

does not take away the experiences faced while engaged in military operations, it attempts to mitigate those

experiences so that Soldiers and units remain combat-effective and ultimately provide the support and

meaning that will allow Soldiers to maintain the quality of life to which they are entitled.

Postcombat and operational stress (PCOS) describes the range of possible outcomes along a continuum of

stress reactions that are experienced weeks or even years after combat and operational stress exposure.

Postcombat and operational stress includes adaptive resolution to the stressors of combat operations (PTG),

mild adjustment reactions, and the more severe negative symptoms that are often associated with

posttraumatic stress disorder (PTSD). Leaders must understand this continuum and know the difference

between adaptation, adjustment, and PTSD. Most Soldiers adapt, but some will struggle with COSRs and,

if unresolved, result in a diagnosis of PTSD.

This publication outlines the effects of combat and operational stress as a manageable leader function. It

describes various types of combat and operational stress behaviors (COSBs) and resulting PCOS as a

function of engaging in and returning from military operations. There are many new tools and resources at

the leader’s disposal to address this issue and provide successful transition and appropriate roles of care to

the Soldiers and organizations entrusted in their care. This manual is designed to provide the unit leader

with information and techniques to recognize and mitigate the effects of combat and operational stress.

However, effective programs and solid leadership are sometimes not enough. The leadership should know

the extended resources available to them and the appropriate mechanisms to utilize them.

The application of COSC management techniques helps conserve the fighting strength, maintain combat

effectiveness in sustained military operations, and promotes resilience and facilitates growth and

management for individuals exposed to PTEs. Combat and operational stress control literally can be the

deciding factor in successfully executing full spectrum operations and winning combat engagements.


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Chapter 1

Combat and Operational Stress Reaction Identification

SECTION I — INTRODUCTION AND HISTORICAL PERSPECTIVE

INTRODUCTION

1-1. Combat and operational stress reactions refer to the adverse reactions personnel may experiencewhen exposed to combat or combat-like situations. Other names that have been used in the past to describe

this reaction include shell shock , Soldier’s heart , battle fatigue, and battle exhaustion

1-2. Combat and operational stress control falls under the force health protection mission and must not beoverlooked or minimized when planning and conducting tactical operations. It is important for Soldiers

and leaders to understand that the effects of combat and operational stress are experienced by all Soldiersin full spectrum operations. Recognizing and managing the effects of combat and operational stress is

equally important during routine training missions as it is during combat. It is the leaders that have the

greatest impact in successfully implementing a COSC program. Leaders must create conditions where

their Soldiers can talk about and make sense of their experiences. They prepare Soldiers before combat by

training them, talking to them, sharing experiences, and making sure they understand the rules of

engagement and the factors that lead to combat and operational stress. The COSC teams and behavioral

health (BH) and medical personnel should be integrated into training and predeployment exercises with

units preparing to deploy.

1-3. Once in theater, leaders should reinforce the mission’s purpose, importance of communicating stress,and involve chaplains by encouraging them to be available to the troops. Leaders should remember that

the more the troops know about normal reactions to extremely abnormal experiences, the more resilient

they will be at dealing with the stress of combat and other military operations. Leaders should not under

estimate their influence on the morale and well-being of Soldiers in their command.

HISTORICAL PERSPECTIVE

1-4. There have been high rates of COSR casualties in all wars over the past 100 years. When the recentSouthwest Asia military operations, (Operation Desert Storm, 1991 and Operation Iraqi Freedom, 2003);

the Afghanistan (Operation Enduring Freedom) and Balkans operations in 2001; or the stability operations

in the Western Hemisphere are compared to World War I or World War II, we notice different types of

conflicts. The levels of intensity in which those conflicts were waged are essentially the same; however,

the lethality of the modern conflicts is potentially greater and the way that conflicts are waged is more

asymmetrical.

1-5. Historically, within US military operations, COSRs have accounted for up to half of all battlefieldcasualties, depending upon the difficulty of the conditions. As a result of COSC being recognized as one

of the ten AMEDD functions that is required for support of full spectrum operations, losses due to COSR

have significantly decreased. In today’s operational environment, leaders can expect to retain and have

returned to duty over 95 percent of the Soldiers who have COSR. Combat and operational stress control is

a tactical consideration that must not be overlooked or minimized.


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SECTION II — REACTIONS TO COMBAT AND OPERATIONAL STRESS

STRESS BEHAVIORS IN FULL SPECTRUM OPERATIONS

1-6. Combat and operational stress behavior is the term that is used to describe the full spectrum ofcombat and operational stress that Soldiers are exposed to throughout their military experience.

1-7. Soldiers—especially leaders—must learn to recognize the symptoms and take steps to prevent orreduce the disruptive effects of combat and operational stress.

1-8. Combat and operational stress is a reality of all military missions. It is important to understand thatcombat and operational experiences affect all Soldiers and reflect all activities that Soldiers are exposed to

throughout the length of their military service whether it is a complete career or a single enlistment.

Combat and operational stress can occur during missions in both garrison and deployed assignments.

1-9. Combat stressors include singular incidents that have the potential to significantly impact the unit orSoldiers experiencing them. They may come from a range of possible sources while performing military

missions. Operational stressors may include multiple combat stressors or prolonged exposures due to

continued operations in hostile environments. Combat and operational stressors have a combined effect

that results in COSRs. See Table 1-1 for examples of both combat stressors and operational stressors.

Table 1-1. Combat stressors and operational stressors

Combat stressors Operational stressors

Personal injury.

Killing of combatants.

Witnessing the death of an individual.

Death of another unit member.

Injury resulting in the loss of a limb.

Prolonged exposure to extreme geographicalenvironments such as desert heat or arctic cold.

Reduced quality of life and communicationresources over extended period of time.

Prolonged separation from significant supportsystems such as Family separation.

Exposure to significant injuries over multiplemissions such as witnessing the death of severalunit members over the course of many combatmissions.

1-10. Most Soldiers are resilient and work through their COSB experiences. The resiliency displayed bythese Soldiers is what we refer to as mental toughness or Battlemind.

1-11. Battlemind skills, developed in military training, provide Soldiers and leaders the inner strength toface fear, adversity, and hardship during combat with confidence and resolution and the will to persevere

and win.

1-12. No amount of training can totally prepare a Soldier for the realities of combat. Sometimes even thestrongest Soldiers are affected so severely that they will need additional help. Combat and operational

stress behavior experiences will impact every Soldier in some way. Just because a Soldier may not be

affected by a specific event, it does not mean that every Soldier in the unit is handling the stress in the

same way.

1-13. Soldiers surveyed in Iraq indicated that those who experienced the most combat were the most likelyto screen positive for a BH problem, including PTSD. Nearly one-third of Soldiers operating outside the

wire may be experiencing severe negative symptoms related to combat and operational stress exposure.

This can potentially affect the unit’s mission capability.

1-14. In fact, current research shows Soldiers continue to struggle with negative PCOS symptoms longafter redeployment. Soldiers do not reset quickly after coming home and up to 17 percent of returned

veterans may continue to struggle with negative PCOS effects even 12 months after coming home.

1-15. Leaders and Soldiers must recognize the continued effects of combat and operational exposure.Understanding these effects will help Soldiers to plan accordingly to support each other and those entrusted


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to them. This is especially important while sustaining prolonged or multiple deployment rotations as well

as combat operations (see Figure 1-1). This model identifies PTEs related to combat and operational

stressors. It looks at COSBs—both adaptive reactions and COSRs—and then looks at PCOS that includes

either PTG or PTSD.

Combat and Operational Stress

Significant PTE

(Combat Stressors)

Multiple PTEs

(Operational Stressors)

Combat and Operational Stress Behaviors

COSRAdaptiveReaction

Postcombat and Operational Stress

PTSDPTG

Figure 1-1. Combat and operational stress effect model

SECTION III — FORMS OF COMBAT AND OPERATIONAL STRESS

POTENTIALLY TRAUMATIC EVENT

1-16. Units and Soldiers deploy and execute military missions which continuously expose them tomilitary-specific stressors. The effects of these stressors are experienced prior to, during, and after

conducting military operations and missions. Sometimes these stressors are related to a significant or

multiple PTEs. A PTE is an event which causes an individual or group to experience intense feelings of

terror, horror, helplessness, and/or hopelessness. It is an event that is perceived and experienced as a threat

to one’s safety or to the stability of one’s world. Units and Soldiers are exposed to or experience PTEsduring both combat and operational military missions.

COMBAT AND OPERATIONAL STRESS BEHAVIORS

1-17. Combat and operational stress behaviors cover the range of reactions found in full spectrumoperations. It covers the range of reactions from adaptive to maladaptive behaviors.


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Adaptive Stress Reactions

1-18. Stressors, when combined with effective leadership and strong peer relationships, often lead toadaptive stress reactions which enhance individual and unit performance. Examples of adaptive stress

reactions are provided in Table 1-2.

Table 1-2. Adaptive stress reactions

Horizontal bonding The strong personal trust, loyalty, and cohesiveness which develops among peersin a small military unit.

Vertical bonding Personal trust, loyalty, and cohesiveness that develops between leaders and theirsubordinates.

Esprit de corps Defined as a feeling of identification and membership in the larger, enduring unitwith its history and intent. This may include the unit (such as battalion, brigadecombat team [BCT], regiment, or other Army organization), the branch (such asinfantry, artillery, or military police), and beyond the branch to the US Army level.

Unit cohesion The binding force that keeps Soldiers together and performing the mission in spiteof danger and adversity.

Cohesion is a result of Soldiers knowing and trusting their peers and

leaders and understanding their dependency on one another .

It is achieved through personal bonding and a strong sense ofresponsibility toward the unit and its members.

The ultimate adaptive stress reactions are acts of extreme courage and

almost unbelievable strength. They may even involve deliberate heroism

resulting in the ultimate self-sacrifice.

Combat and Operational Stress Reaction

1-19. The Army uses the DOD-approved term/acronym COSR in official medical reports. This term can be applied to any stress reaction in the military unit environment. Many reactions look like symptoms of

mental illness (such as panic, extreme anxiety, depression, and hallucinations), but they are only transient

reactions to the traumatic stress of combat and the cumulative stresses of military operations. Some

individuals may have behavioral disorders that existed prior to deployment or disorders that were first

present during deployment and may need BH intervention beyond the interventions for COSR.

1-20. The COSR casualties are Soldiers who become combat ineffective due to unresolved negativeCOSRs.

1-21. Misconduct stress behavior is a form of COSR and most likely to occur in poorly trained,undisciplined units. Even so, highly trained, highly cohesive units, and individuals under extreme combat

and operational stress may also engage in misconduct. Generally, misconduct stress behaviors―

Range from minor breaches of unit orders or regulations to serious violations of the Uniform

Code of Military Justice (UCMJ) and of the Law of Land Warfare.

May also become a major problem for highly cohesive and proud units. Such units may come to

consider themselves entitled to special privileges and, as a result, some members may relieve

tension unlawfully when they stand-down from their military operations. For example, they

may lapse into illegal revenge when a unit member is lost in combat.

Can be prevented by stress control measures and sound leadership, but once serious misconducthas occurred, Soldiers must be punished to prevent further erosion of discipline. Combat stress,

even with heroic combat performance, cannot justify criminal misconduct and does not remove

responsibility from anyone who commits such an act.

Postcombat and Operational Stress

1-22. Postcombat and operational stress describes a range of possible outcomes along the continuum ofstress reactions which may be experienced weeks or even years after combat and operational stress

exposure. Postcombat and operational stress includes the adaptive resolution (PTG) to the stressors of


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combat operations, mild COSR, and the more severe symptoms that are often associated with PTSD.

Leaders, Soldiers, and health care providers must understand this continuum and know the difference

between adaptation, COSR, and PTSD.

Posttraumatic Growth

1-23. Posttraumatic growth refers to positive outcomes that result from stress exposure and traumatic

experiences that include improved relationships, renewed hope for life, an improved appreciation of life, anenhanced sense of personal strength, and spiritual development.

Posttraumatic Stress Disorder

1-24. Posttraumatic stress disorder is a psychiatric illness that can occur following a traumatic event (suchas combat exposure) in which there was a threat of injury or death to you or someone else.

COMBAT AND OPERATIONAL STRESS R EACTION AND POSTTRAUMATIC STRESS DISORDER

1-25. Leaders must understand the difference between COSR and PTSD. Combat and operational stressreaction is not the same as PTSD. Combat and operational stress reaction represents the broad group of

physical, mental, and emotional signs that result from combat and operational stress exposure which

includes— Combat and operational stress reaction which is considered a subclinical diagnosis with a high

recovery rate if provided appropriate attention and time.

Posttraumatic stress disorder which is an anxiety disorder associated with serious traumatic events

and characterized by such symptoms as survivor guilt, reliving the trauma in dreams, numbness

and lack of involvement with reality, or recurrent thoughts and images. Posttraumatic stress

disorder is a clinical diagnosis as defined by the Diagnostic and Statistical Manual of Mental

Disorders and the International Statistical Classification of Diseases and Related Health

Problems (ICD-10) in Occupational Health.

1-26. Combat and operational stress reaction and PTSD may share some common symptoms, however,COSR is recognizable immediately or shortly after exposure to traumatic events and captures any

recognizable reaction resulting from exposure to that event or series of events. Posttraumatic stress

disorder is different from COSR because of its specific chronological requirements and symptom markers

that must be satisfied in order to diagnose. Posttraumatic stress disorder is only diagnosable by a trained

and credentialed health care provider. See Appendix A for additional information on PTSD and mild

traumatic brain injuries (MTBIs).

CONTINUUM OF COMBAT AND OPERATIONAL STRESS R EACTIONS

1-27. The distinctions among adaptive stress reactions, misconduct stress behaviors, COSR casualties,PTG, and PTSD are not always clear. Indeed, the categories of COSBs may overlap. Soldiers with COSR

may show misconduct stress behaviors and vice versa. Soldiers with adaptive stress reactions may also

suffer from COSR. Soldiers exposed to danger may experience physical and emotional reactions that are

not present in their daily activities. Some reactions sharpen abilities to survive and win; other reactions

may produce disruptive behaviors and threaten individual and unit safety. Excellent combat Soldiers that

have exhibited bravery and acts of heroism may also commit misconduct stress behaviors.

1-28. Postcombat and operational stress may develop after someone has experienced or witnessed anactual or threatened traumatic event. If PCOS interferes with the ability to do jobs and enjoy life, and it

seems to continually get worse, it could lead to an actual BH diagnosis known as PTSD. Most Soldiers

will do well but for some, persistent symptoms of PCOS may need support or medical care.

1-29. Soldiers in combat experience a range of emotions, but their behavior influences immediate safetyand mission success. Combat and combat-related military missions can also impose combinations of heavy

physical work; sleep loss; dehydration; poor nutrition; severe noise, vibration, and blast exposure; exposure


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to heat, cold, or wetness; poor hygiene facilities; and perhaps exposure to infectious diseases and toxic

fumes or substances.

1-30. This range of emotions and mission-related conditions in combination with other influences—suchas concerns about problems back home—affect the ability to manage the perceived or real danger and

diminish the skills needed to accomplish the mission. Additional factors that may influence stress levels

and leader considerations include—

Environmental stressors often play an important part in experiencing adverse or disruptive

COSR. The leader must work to keep each Soldier’s perception of danger balanced by the sense

that the unit has the means to prevail over it.

When troops begin to lose confidence in themselves and their leaders, adverse stress reactions

are most likely to occur. The leader must keep himself and his unit working at the level of stress

that enhances performance and confidence.

The importance of leaders to recognize COSRs in order to intervene promptly for the safety of

the Soldier and organization.

Combat and operational stress behaviors may take many forms and can range from subtle to

dramatic. Trying to memorize every possible sign and symptom is less useful than being alert

for sudden, persistent, or progressive changes in a Soldier’s behavior, especially if the Soldier is

a threat to himself or the functioning and safety of the unit.

SECTION IV — OBSERVING AND RECOGNIZING COMMON REACTIONS TO

COMBAT AND OPERATIONAL STRESS

COMBAT AND OPERATIONAL STRESS REACTIONS MAY AFFECT

SOLDIERS IN ALL TYPES OF MILITARY OPERATIONS

1-31. Mild stress reaction may be signaled by changes in behavior and discernible only by the individualSoldier or by close comrades. Without self-report, it can be difficult to observe stress-related changes.

The unit leader and medical personnel depend on information from the Soldier or his comrades for early

recognition of COSR to provide prompt and appropriate help. Some mild stress reactions (physical and

emotional) that the small-unit leader should look for are listed in Table 1-3.

1-32. Severe stress reactions may prevent the individual from performing his duties or create a concern for personal safety or the safety of others. More serious reactions or warning signs are listed in Table 1-4.

1-33. The reactions that are listed in Table 1-4 do not necessarily mean that the person must be relievedfrom duty, but warrant immediate evaluation and help by leadership. If not provided support, Soldiers may

become COSR casualties.


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Table 1-3. Mild stress reactions

Physical Emotional

Trembling

Jumpiness

Cold sweats, dry mouth

Insomnia

Pounding heart

Dizziness

Nausea, vomiting, or diarrhea

Fatigue

Thousand-yard stare

Difficulty thinking, speaking, and communicating

Anxiety, indecisiveness

Irritability, complaining

Forgetfulness, inability to concentrateNightmares

Easily startled by noise, movement, and light

Tears, crying

Anger, loss of confidence in self and unit

Table 1-4. Severe stress reactions

Physical Emotional

Constantly moves around

Flinches or ducks at sudden sound or movement

Shakes, trembles

Cannot use part of body (hand, arm, or leg) for noapparent physical reason

Inability to see, hear, or feel

Is physically exhausted, cries easily

Freezes under fire or is totally immobile

Panics, runs under fire, socially withdrawn

Talks rapidly and/or inappropriately

Argumentative; acts recklessly

Indifferent to danger

Memory loss

Stutters severely, mumbles, or cannot speak at all

Insomnia; severe nightmares

Sees or hears things that do not exist

Apathetic, hysterical outbursts, frantic, or strangebehavior

1-34. The most common stress reactions include—

Fatigue:

Slow reaction time.

Difficulty sorting out priorities.

Difficulty starting routine tasks.

Excessive concern with seemingly minor issues.

Indecision and difficulty focusing attention as evidenced by a tendency to do familiar tasks

and preoccupation with familiar details. These reactions may reach a point where the

person becomes very passive or wanders aimlessly.

Loss of initiative with fatigue and exhaustion.

Muscular tension:

Often increases strain on the scalp and spine (backache) and often leads to headaches, pain,

and cramps.

The inability to relax because of prolonged muscular tension wastes energy and leads tofatigue and exhaustion. Muscles must relax periodically to enable free blood flow, waste

product flushing, and nutrient replenishment.

Shaking and tremors:

During incoming rounds, the individual may experience mild shaking. This symptom

appears and disappears rapidly and is considered a normal physiological reaction to

conditions of great danger.


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A common postbattle reaction, marked or violent shaking can be incapacitating if it occurs

during the action. If shaking persists long after the precipitating stimulus ceases or if there

was no stimulus, the individual should be checked by medical personnel.

It is normal to experience either mild or heavy sweating (perspiration) or sensations of

chilliness under combat stress.

Digestive and urinary systems:

Nausea (butterflies in the stomach) is a common stress feeling. Vomiting may occur as aresult of an extreme experience like that of a firefight, shelling, or in anticipation of danger.

Appetite loss may result as a reaction to stress. It becomes a significant problem if rapid

weight loss occurs or the person does not eat a sufficiently balanced diet to keep his

muscles and brain supplied for sustained operations.

Acute abdominal pain (knotted stomach, heartburn) may occur during combat. Persistent

and severe abdominal pain is a disruptive reaction and may indicate a medical condition.

Frequent urination may occur, especially at night.

During extremely dangerous moments, the inability to control bowel and/or bladder

functions (incontinence) may occur. Incontinence is embarrassing, but it is not abnormal

under these circumstances.

Circulatory and respiratory systems:

Rapid heartbeat (heart palpitations), a sense of pressure in the chest, occasional skipped beats, and sometimes chest pains are common with anxiety or fear. Very irregular

heartbeats need to be checked by medical personnel.

Hyperventilation is identified by rapid respiration, shortness of breath, dizziness, and a

sense of choking. It is often accompanied with tingling and cramping of fingers and toes.

Simple solutions are increased exercise and breathing with a paper bag over the nose and

mouth or breathing slowly using abdominal muscles (called abdominal breathing).

Faintness and giddiness reactions occur in tandem with generalized muscular weakness,

lack of energy, physical fatigue, and extreme stress. Brief rest should be arranged, if

possible.

Sleep disturbance:

Sometimes a Soldier who has experienced intense battle conditions cannot fall asleep even

when the situation permits or when he does fall asleep, he frequently wakes up and hasdifficulty getting back to sleep (refer to Chapter 4 for a complete discussion on sleep

deprivation).

Terror dreams, battle dreams, and nightmares of other kinds cause difficulty in staying

asleep. Sleep disturbances in the form of dreams are part of the coping process. This

process of working through combat experiences is a means of increasing the level of

tolerance of combat stress. The individual may have battle-related nightmares or dreams

that a close relative (such as a spouse or parent) or another person important in his life has

been killed in the battle. As time passes, the nightmares tend to occur with less intensity

and less frequency. In some cases, a Soldier, even when awake, may experience the

memory of the stressful incident as if it were recurring (called a flashback ). This is usually

triggered by a smell, sound, or sight, and is not harmful as long as the Soldier realizes it is

only a memory and does not react inappropriately or feel overwhelmed. However, if it

happens frequently or is very distressing, help should be sought from the chaplain ormedical personnel.

When a person is asleep, the sleep is not restful sleep if the person is constantly being half-

wakened by noise, movement, or other stimuli. Heavy snoring often indicates poor quality

sleep. The individual wakes up as tired as when he went to sleep. Finding a more

comfortable position, away from distractions, can help.

Individuals exhibiting a need for excessive sleep may be exhibiting symptoms of combat

stress; however, excessive sleep is also a sign of substance abuse or depression. (Persistent

insomnia is a more common indicator of possible depression.)


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Visual and hearing problems and partial paralysis:

Stress-related blindness, deafness, loss of other sensations, and partial paralysis are not true

physical injuries, but physical symptoms that unconsciously enable the individual to escape

or avoid a seemingly intolerably stressful situation. These symptoms can quickly improve

with reassurance and encouragement from comrades, unit medical personnel, or physician.

If they persist, the physician must examine the Soldier to be sure there is not a physical

cause; for example, laser hazards (such as laser range finders) can cause temporary or partial blindness and nearby explosions can cause ear damage. Individuals with these

physical conditions are unaware of the causative relationship with their inability to cope

with stress. These cases are genuinely concerned with their physical symptoms and want

to get better. They are willing to discuss them and do not mind being examined. This is

contrary to malingerers faking a physical illness, who are often reluctant to talk, or who

over-dramatize their disability and refuse an examination.

Visual problems include blurred vision, double vision, difficulty in focusing, or total

blindness.

Hearing problems include the inability to hear orders and/or nearby conversations or

complete deafness occurs.

Paralysis or loss of sensation is usually confined to one arm or leg. Prickling sensations or

rigidity of the larger joints occur. However, temporary complete immobility (with normal breathing and reflexes) can occur. If these reactions do not recover quickly with

immediate reassurance, care must be taken in moving the casualty to medical treatment

facility (MTF) for an evaluation to avoid making a possible nerve or spinal cord injury

worse.

Bodily arousal: Not all emotional reactions to stress are necessarily negative. For example, the

body may become aroused to a higher degree of awareness and sensitivity.

Threat:

In response to threat, the brain sends out chemicals arousing the various body systems. The

body is ready to fight or take flight .

The alerting systems of the experienced combat veteran become finely tuned, so that he

may ignore loud stimuli that pose no danger (such as the firing of nearby friendly artillery).

However, he may awaken from sleep at the sound of an enemy mortar being fired and take

cover before the round hits.

The senses of vision and smell can also become very sensitive to warning stimuli. The

Soldier may instantly focus and be ready to react.

Hyperalert:

This refers to being distracted by any external stimuli that might signal danger and

overreacting to things that are, in fact, safe. The hyperalert Soldier is not truly in tune with

his environment, but is on a hair trigger.

The hyperalert Soldier is likely to overreact and consequences can range from firing at an

innocent noise to designating an innocent target as hostile, or misinterpreting reassuring

information as threats, and reacting without adequate critical thinking.

Startle reactions:

This is part of an increased sensitivity to minor external stimuli (on-guard reactions).

Leaping, jumping, cringing, jerking, or other forms of involuntary self-protective motor

responses to sudden noises are noted. The noises are not necessarily very loud.

Sudden noise, movement, and light cause startle reactions; for example, unexpected

movement of an animal (or person) precipitates weapon firing.

Anxiety:

Fear of death, pain, and injury causes anxiety reactions. After witnessing the loss of a

comrade in combat, a Soldier may lose self-confidence and feel overly vulnerable or

incapable.


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The death of a buddy leads to serious loss of emotional support. Feelings of survivor guilt

are common.

The survivors each brood silently, second-guessing what they think they might have done

differently to prevent the loss. While the Soldier feels glad he survived, he also feels guilty

about having such feelings. Understanding support and open grieving shared within the

unit can help alleviate this.

Irritability: Mild irritable reactions range from angry looks to a few sharp words, but can progress to

more serious acts of violence. Mild irritability is exhibited by sharp, verbal overreaction to

normal, everyday comments or incidents; flare-ups involving profanity; and crying in

response to relatively slight frustrations.

Severe irritability includes sporadic and unpredictable explosions of aggressive behavior

(violence) which can occur with little or no provocation. For example, a Soldier tries to

pick a fight with another Soldier. The provocation may be a noise (such as the closing of a

window, an accidental bumping, or just normal verbal interaction).

Short attention span:

Persons under pressure have short attention spans.

Soldier finds it is difficult to concentrate.

Soldier has difficulty following orders. Soldier does not easily understand what others are saying.

Soldier has difficulty following directions, aiding others, or performing unfamiliar tasks.

Depression:

Soldier responds to stress with protective defensive reactions against painful perceptions.

Emotional dulling or numbing of normal responsiveness is a result.

The reactions are easily observed changes from the individual’s usual self.

Low energy level:

Decreased effectiveness on the job, decreased ability to think clearly, excessive sleeping or

difficulty falling asleep, and chronic tiredness can occur.

Emotions such as pride, shame, hope, grief, and gratitude no longer matter to the person.

Social withdrawal: The Soldier is less talkative than usual and shows limited response to jokes or cries.

He is unable to enjoy relaxation and companionship, even when the tactical situation permits.

Change in outward appearance:

If the Soldier is in a depressed mood, he may be observed to exhibit very little body

movement and to have an almost expressionless mask-like face.

The Soldier may present disheveled in appearance, with reduced personal hygiene, and

with little military bearing.

Substance abuse:

Some Soldiers may attempt to use substances such as alcohol or drugs as a means of

escaping combat and operational stress.

The use of substances in a combat area makes some Soldiers less capable of functioning on

the job. These Soldiers are less able to adapt to the tremendous demands placed on them incombat.

Loss of adaptability:

Less common reactions include uncontrolled emotional outbursts such as crying, yelling, or

laughing.

Some Soldiers may become withdrawn, silent, and try to isolate themselves.

Uncontrolled reactions can appear singly or in combination with a number of other

symptoms. In this state, the individual may become restless, unable to keep still, and move

aimlessly about.


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The Soldier may feel rage or fear (which he demonstrates by aggressive acts [angry

outbursts or irritability]).

Disruptive reactions:

Soldiers with disruptive COSR cannot function on the job.

In some cases, stress produces signs and symptoms often associated with head injuries. For

example, the person may appear dazed and may wander around aimlessly. He may appear

confused and disoriented and exhibit either a complete or partial memory loss. Soldiers exhibiting this behavior should be removed from duties until the cause for this

behavior can be determined.

These Soldiers may compromise their own safety—in a desperate attempt to escape the

danger that has overwhelmed them.

An individual Soldier may panic and become confused. The term panic run refers to a

person rushing about without self-control. In combat, such a Soldier can easily

compromise his safety and could possibly get killed. His mental ability becomes impaired

to the degree that he cannot think clearly or follow simple commands. He stands up in a

firefight because his judgment is clouded and he cannot understand the likely consequences

of his behavior. He loses his ability to move and seems paralyzed. A person in panic is

virtually out of control and needs to be protected from himself. More than one person may

be needed to exert control over the individual experiencing panic. However, it is alsoimportant to avoid threatening actions, such as striking him.

They may compromise the safety of others—if panic is not quelled early, it can easily

spread to others.

1-35. Although the more serious or warning behaviors described in the preceding paragraphs usuallydiminish with help from comrades and small-unit leaders and time, some do not. Soldiers can improve

when their basic needs are met and they are given the opportunity to express their thoughts.

1-36. If a Soldier’s signs and symptoms do not improve within 1 to 2 days or when symptoms endangerthe Soldier or organization, leadership should immediately consult with the unit chaplain or medical

personnel. Consultation with BH/COSC personnel is recommended when available.

SECTION V — ROLE OF THE UNIT MINISTRY TEAM

UNIT MINISTRY TEAM SUPPORT

1-37. This section addresses the general role of the unit ministry team (UMT) in the commander’s programof COSC and in COSR ministry. The UMT is assigned to a command or designated by higher

headquarters to be responsible for the direct UMT support to the command. The UMT provides

professional ministry support to leaders in fulfilling their combat and operational stress identification and

intervention responsibilities. The UMT can also assist in training leaders to recognize combat stress

symptoms.

1-38. The unit is organic to Army units at all echelons from battalion and above. The UMT’s primarymission is to provide for the personal delivery of religious support to Soldiers and other authorized

personnel. Because the UMT is an integral part of the unit, it is a resource immediately available to the

commander to assist with COSC.1-39. The UMT consists of at least one chaplain and one chaplain’s assistant. The UMT also provides areareligious support in their unit’s area of operations for assigned or attached units without organic religious

support assets.

1-40. During combat operations, the UMT often collocates with the battalion aid station in order to providereligious support to casualties and to be with Soldiers who are most likely to experience COSR. Using their

professional training, skills, knowledge, and relationship with the Soldiers, chaplains provide religious and

spiritual support focusing on the prevention of mild and severe COSR. Chaplains also provide religious

support to COSR casualties as an important part of the replenishment process.


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1-41. In addition to being a spiritual/religious mentor for Soldiers, chaplains are trained in the TEM process and are able to assist the TEM facilitator. Chaplains are effective TEM team members as well as

trainers of small-unit leaders (such as platoon leaders, noncommissioned officers [NCOs], senior combat

medics, and health care specialists) in TEM team member skills and stress management techniques. (See

FM 1-05, for further information on the role and functions of the UMT.)

1-42. The UMT can assist commanders in the identification of Soldiers experiencing COSR. Chaplains

work closely with the unit medical personnel and are trained to recognize the signs of combat andoperational stress and provide religious support to Soldiers experiencing COSR. Chaplains assess the

Soldier’s religious needs and then provide the appropriate religious support. Chaplains are also trained to

evaluate Soldiers experiencing COSR for possible referral to medical, BH, or COSC unit personnel. When

advising commanders on COSR among Soldiers, chaplains must ensure that they do not violate Soldier’s

rights to privileged communications.

1-43. The UMT can help Soldiers regain their emotional, psychological, and spiritual strength. Thechaplain’s ability to relate religious and spiritual aspects of life to the Soldier’s situation is an essential

element of the replenishment process. Chaplains contribute to replenishment by ensuring the following

types of religious support:

Providing worship services, sacraments, rites, and ordinances.

Providing memorial services and/or ceremonies honoring the dead.

Assisting with the integration of personnel replacements. Providing personal counseling to assist Soldiers dealing with the grief process.

Requesting religious resources as required for reinforcing the Soldier’s sense of hope.

Supporting TEM by providing opportunities for Soldiers to talk about their combat experiences

and to facilitate integration of the combat experience into their lives.

Providing leadership training and supervision of TEM.

Reconnecting the Soldier to the foundational principles of his personal faith.

Assisting in resolving spiritual, moral, and ethical dilemmas presented by the circumstances of

war.

SECTION VI― ROLE OF UNIT BEHAVIORAL HEALTH ASSETS

MENTAL HEALTH SECTIONS

1-44. Mental health (MH) sections are located in medical companies assigned to brigade and echelonsabove brigade medical units. The primary warfighting units for the Army are the modular brigades that

include infantry, heavy brigade, and the Stryker BCTs (see FM 3-90.6 for definitive information on the

modular BCTs).

1-45. Each BCT medical company has a two-person MH section consisting of one area of concentration67D (either a psychologist or a social work officer) and one enlisted MH specialist (military occupational

specialty 68X10).

1-46. The MH section coordinates, supervises, and provides the primary COSC functions for the BCTthrough vigorous prevention, consultation, training, education, and Soldier restoration programs. These

programs are designed to provide COSC expertise to unit leaders and Soldiers where they serve to sustain

their mission focus and effectiveness under heavy and prolonged stress.


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1-47. The MH section has a primary responsibility for assisting leaders with COSC by implementing the brigade COSC program. The MH section—

Is the consultant to the commander, staff, and others involved with providing prevention and

intervention services to unit Soldiers and their Families.

Is responsible for assisting the brigade surgeon with establishing brigade policy and guidance

for the prevention, diagnosis, treatment, management, and return to duty (RTD) of stress-related

casualties. This is accomplished under the guidance and in close coordination with all of the

maneuver battalions and the brigade support medical company (BSMC) physicians.

Is qualified to conduct command consultations per DODD 6490.1 (refer to Section VII below).

Consultation should not be confused with evaluation. Only physicians and doctoral-level

providers are qualified to conduct command directed evaluation.

1-48. The BH officer (either a clinical psychologist or social work officer) and MH specialist areespecially concerned with assisting and training of—

Small-unit leaders.

Unit ministry teams and staff chaplains.

Battalion medical platoons.

Patient-holding squad and treatment squad personnel of the medical company.

1-49. They work closely with unit leaders and chaplains to control organizational stress and rapidlyidentify and intervene with those Soldiers that may need assistance. Unit leaders should seek the expertise

of the BSMC BH personnel and include them in their planning processes prior to deployment.

1-50. All MH sections regardless of their organizational assignment are tasked with providing COSC fortheir supported units. In all of these units, COSC is accomplished through vigorous prevention,

consultation, training, education, and Soldier restoration programs. These programs are designed to

provide BH expertise to unit leaders and Soldiers where they serve and sustain their mission focus and

effectiveness under heavy and prolonged stress.

1-51. The MH sections identify Soldiers with COSRs who need to be provided rest/restoration within ornear their unit area for rapid RTD. These programs are designed to maximize the RTD rate of Soldiers

who are either temporarily impaired, have a diagnosed behavioral disorder, or have stress-related

conditions.

1-52. The MH section has a primary responsibility for assisting commanders with COSC by implementingthe brigade COSC program and serves as a consultant to the commander, staff, and others involved with

providing prevention and intervention services to unit Soldiers and their Families.

1-53. In garrison, BH personnel assigned to the BSMC and to echelons above brigade medical unitscontinue to perform the same staff and outreach functions with supported units as they do in a field

environment. An increase in the BH treatment functions may be possible as a result of consolidating BH

care providers. The BH providers make available their consultation skills and clinical expertise to Soldiers

of supported units and their Family readiness groups (FRG). Clinical care of Family members and Soldiers

that require longer-term care beyond crisis intervention, brief treatment, and medication follow up is the

responsibility of the medical department activity/medical center. The MH section personnel should focus

their clinical work primarily on Soldiers with problems amenable to brief treatment.

1-54. Clinical services may be provided as part of a consolidated BH activity that is normally coordinatedand established by a senior medical headquarters by using brigade BH support personnel and personnelfrom the medical detachment, combat stress control, or by augmenting an existing medical department

activity/medical center BH staff.

1-55. Mental health sections should work closely with unit leaders and chaplains to control organizationalstress and rapidly identify and intervene with those Soldiers having BH disorders. This close relationship

through command consultation will reduce the stigma and lead to a better outcome for both the leadership

and Soldiers. See Appendix B for additional information on behavioral and personality disorders.


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1-56. When the medical company or its battalion deploys on training exercises, assigned BH personneldeploy with them to provide COSC training and support. In addition, they train to improve their own

technical and tactical skills.

SECTION VII — REFERRALS OF SOLDIERS EXPERIENCING COMBAT AND

OPERATIONAL STRESS REACTION AND/OR OTHER STRESS-RELATED

DISORDERS

RECOGNIZE SEVERE STRESS REACTIONS

1-57. Although the more serious or warning behaviors described in the preceding paragraphs usuallydiminish with help from peers, unit leaders, and time; some do not. An individual usually improves when

basic need and comforts are met. Examples of these are warm food, rest, and an opportunity to share his

feelings with comrades or a small-unit leader. If the symptoms endanger the individual, others, or the

mission or if they do not improve within a day or two, or seem to worsen, get the individual to talk with the

unit chaplain, health care providers, or BH/COSC asset. Access to MH specialists may be sought, if

available. Do not wait too long to see if the Soldier’s behavior is better with time. Specialized training is

not required to recognize severe stress reactions. The unit leader can usually determine if the individual is

not performing his duties normally, not taking care of himself, behaving in an unusual fashion, or acting

out of character.

1-58. Unit leaders have multiple levels of COSC support services available to them, some organic to theirorganizations, some attached, and some area or garrison support. It is up to the small-unit leader to identify

what resources are available in their local and extended area. The following assets are generally available

to leadership, in tactical environments—

Organic medical assets to include physicians, physician assistants, health care specialists, and

combat medics.

Chaplains.

Behavioral health assets organic and/or attached to the organization.

Combat and operational stress control team that is working in the unit’s area of operation.

VOLUNTARY R EFERRALS 1-59. When there are signs of distress that may be negatively impacting a Soldier’s functioning, commandscan encourage the individual to voluntarily seek help. Active duty Soldiers who voluntarily seek help will

be evaluated and offered appropriate treatment. With some exceptions, information provided will be kept

private. These exceptions include—

Removal from weapon-bearing duties or access to classified information is recommended.

Significant risk of danger to self or others is present.

The Soldier represents a significant security risk.

Hospitalization is necessary.

Domestic violence or child abuse is suspected or reported or a diagnosis of substance abuse or

dependence is made (Family Advocacy Program restricted reporting policy may apply).

The Soldier’s BH has deteriorated to the point that it may significantly affect work or Family

function.

COMMAND-DIRECTED EVALUATION

1-60. The commander may direct Soldiers to undergo a command-directed evaluation (CDE) according toDODD 6490.1 and DODI 6490.4 for a BH evaluation. A CDE is appropriate whenever the commander

believes that the Soldier’s mental state renders him a risk to himself or others or may be affecting his

ability to carry out the mission. A CDE can provide the commander with information needed to initiate the

appropriate administrative action. Examples of questions commanders may pose include—


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Does the Soldier have a BH or neuropsychiatric condition that is contributing to his current

difficulty?

What is the potential for the Soldier to return to full functioning given successful treatment?

Is the Soldier suitable for carrying a weapon at the current time?

Is it appropriate for the Soldier to have access to classified information?

Is the Soldier qualified for deployment?

Is this an emergency or can the CDE be accomplished on a routine basis?

Routine Command-Directed Evaluation

1-61. Once a decision has been made to request a routine/nonemergency CDE, commanders are requiredto—

Consult with a privileged BH provider. Commanders should communicate the behaviors that

they believe warrant the evaluation and what information they would like from an evaluation.

The BH provider will make recommendations about whether a CDE is appropriate and if the

situation warrants an emergency CDE. The BH provider will also discuss other options that

may be appropriate. If a CDE is necessary, the commander should inform the provider as to

when the Soldier will be notified about the referral so that a time and date for the evaluation can

be determined.

Provide a written letter or counseling statement to the Soldier. This should be provided to the

Soldier at least two working days prior to the evaluation. The letter will include—

The date, time, and location of the evaluation.

The name and grade or rank of the BH professional who will be conducting the evaluation.

The name and grade or rank of the BH professional with whom the command has consulted.

A brief factual description of the behavior that gave rise to the need for a referral.

A listing of the Soldier’s rights.

The names and telephone numbers of the resources on-post that can assist the Soldier.

The name and signature of the commander.

Soldier’s acknowledgement of receipt of letter by signing or commander’s annotation of

Soldier’s refusal.

1-62. Most BH assets will have copies of templated sample CDE request forms. Leaders should contacttheir supporting BH asset to request a copy of this form.

1-63. Forward a request for a CDE to the provider. It is vital for the Soldier’s command to provide allavailable documentation concerning the problem behaviors. This may include, as available, Article 15s,

letters of reprimand, letters of counseling, and enlisted performance reports/officer performance reports.

The documentation is necessary for a comprehensive evaluation.

1-64. Provide a copy of the letter to the BH provider conducting the CDE. If the provider believes that theevaluation has been requested improperly, he will contact the command to clarify issues about the process

or procedures used. The provider conducting the evaluation will provide both written and verbal feedback

on the results of the evaluation. Be aware the evaluation may require more than one appointment to

complete.

Emergency Command-Directed Evaluations

1-65. Emergency CDEs are conducted upon recommendation of the BH provider or when in the judgmentof the command an emergent situation exists. In general the following constitute grounds for an

emergency referral:

A severe mental or substance use disorder.

Intent to inflict harm to self or others.

Actual, attempted, or threatened violence.


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1-66. When an emergency CDE is determined to be necessary, adhere to the following steps:

Ensure safety of the Soldier and others by—

Observing the Soldier and never leaving him alone.

Taking away all weapons, knives, medication, or other objects that could harm him or

others.

Taking all reasonable precautions to notify and protect others who have been identified as

intended targets of violence or harm.

Consulting with BH or other privileged health care provider prior to sending a Soldier for

an emergency CDE, if at all possible. If the circumstances do not permit such a

consultation, contact other supporting medical personnel as soon as possible.

Take action to safely transport the Soldier to the nearest BH care provider, or if unavailable,

another privileged health care provider as soon as is practical. Provide—

The Soldier with a letter stating the reasons for emergency referral as soon as practical. If

the Soldier is seen before the letter can be provided, the letter and statement of rights must

be provided as soon as is practical. If a BH provider was not consulted prior to ordering

the CDE, the reason why should be explained in the letter to the Soldier.

A letter to the evaluating provider. A letter requesting a CDE must be sent to the treating

BH provider documenting command concerns, the Soldier’s circumstances, and the

observations that led to refer emergency referral. This should be done as soon as possible.

Rights of Soldiers Pertaining to a Command-Directed Evaluation

1-67. Legal protections for the rights of Soldiers prohibit a command from improperly referring for a CDE.It is improper to refer a Soldier for a CDE to buy time, as a disciplinary tool, or as a reprisal for the

individual’s attempt or intent to make a lawful communication (see DODD 6490.1). When referred for a

nonemergency CDE when deployed in theater, the following rights prior to the evaluation apply. The

Soldier may—

Have two working days waiting period between the CDE notification and evaluation.

Consult with and get advice from an attorney (judge advocate).

Consult with the inspector general if he believes the CDE violates policy.

Request a second BH evaluation by another BH provider of the Soldier's choice and expense, if

reasonably available.

Not have his rights restricted from communicating with the inspector general, members of

Congress, or any others concerning the BH referral.

Coordination Between the Commander and Behavioral Health Provider for a Command-Directed Evaluation

1-68. A commander can expect the BH provider to keep him informed and to request additionalinformation following a CDE request which may include—

Requesting documents supportive of the request for a CDE (documentation of problem

behaviors, letters of reprimand or counseling, Article 15s, and past performance reports).

Requesting interviews with unit leaders, immediate supervisors, or other appropriate personnel

to obtain collateral information on the individual. Performing psychological testing or conducting clinical interviews with the Soldier.

1-69. The commander will be notified by the BH provider when the Soldier—

Requires hospitalization.

Requires evacuation out of theater.

Has any limitations placed on his duty status.


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1-70. Verbal and written reports summarizing findings and recommendations will be discussed with bothcommander and the Soldier. Recommendations may include suggestions for support, changes in special

duty status, and/or separation from the Army.


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Chapter 2

Combat and Operational Stress Prevention, Management,and Control

SECTION I — INTRODUCTION AND FACTORS WHICH INFLUENCE COMBAT

AND OPERATIONAL STRESS AND LEADER ACTIONS

INTRODUCTION

2-1. The previous chapter defined combat and operational stress and how to utilize additional resourcesto aid in the management of Soldiers with significant COSR. The rest of this manual will provide

information, recommendations, and tools for the leader in preventing and managing combat and

operational stress. There are key risk factors that have the potential to create significant distress for theSoldier that small-unit leaders must be aware of. Each factor is presented below with recommendations on

how to mitigate the potential COSR resulting from the specific stressor

COMBAT AND OPERATIONAL STRESS CONTROL RISK FACTORS

OR STRESSORS AND PREVENTIVE MEASURES OR LEADER

ACTIONS

2-2. The following tables (Tables 2-1 through 2-9 on pages 2-1 through 2-7) identify risk factors or stressorsand preventive measures or leader actions that are required to reduce or eliminate the risk factors or

stressors. Subsequent sections of this chapter provide additional guidance and tools for Soldiers and

leaders in the prevention and management of combat and operational stress.

Table 2-1. Combat and operational stress control risk factors or stressors andpreventive measures or leader actions

Risk factor or stressor Preventive measure or leader action

Intense or heavy combat.

Under attack and unable tostrike back.

Troops may feel like helplessvictims of pure chance.

Immobility—during static, heavy

fighting.

Pinned down in bunkers,trenches, or ruins. Armoredtroops on restrictive terrain.Close quarters during urbancombat.

Consider coordinating a unit BH needs assessment survey (UBHNAS) to assess BH of unit ata scheduled point in the deployment cycle (midpoint, quarterly, or so forth). This will allowvisibility of BH of unit as a whole, especially if compared to UBHNAS results prior todeployment. Allows the refinement of the unit COSC program to address relevant issues.

Ensure that unit understands the rules of engagement (ROEs) and behavior expectations.Remind Soldiers of the intent to return with honor .

Conduct activities that allow continued bonding and development of unit cohesion and espritde corps.

Conduct rugged and realistic training.

Train troops in active defense against these threats.

Institute protective measures for trench, bunker, or urban operations.

Understand that stress in response to threatening or uncertain situations is a normal reaction.

Recognize that battle duration and intensity increases the potential for COSR. Convey thismessage to Soldiers.

Impart unit pride and identity.


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Table 2-2. Environmental and physical risk factors or stressors andpreventive measures or leader actions


Lengthy, ongoingdeployments creatingcumulative stress.

Extreme temperatures.

Precipitation.

Austere conditions.

Sand and windstorms.

Poor air quality.

Dietary changes.

Exposure to disease.

Crowded living conditions

and lack of privacy.Jet lag upon arrival.

Physical demands.

Fatigue-producing eventsand activities.


Ensure every effort is made to provide for Soldiers’ health and welfare.

Promote regular and proper hygiene.

Provide Soldier’s with appropriate equipment for weather-related conditions.

Institute sleep management program.

Ensure proper nutrition and hydration.

Initiate and support stress management program.

Develop and supervise safety policies and procedures.

Promote individual and unit physical training.

Consult with preventive medicine and other force health protection personnel.

Consult with BH and COSC teams.Encourage Soldiers to self-refer.

Foster a command climate that encourages seeking help for problems.

Encourage use of sick call when physical symptoms are present.

Prohibit the use of self-medication; only use medication if prescribed andmonitored by health care providers.

Table 2-3. Unit casualties and other potentially traumatic event risk factors orstressors and preventive measures or leader actions


Soldiers in the unit beingkilled and wounded arethe strongest indicator ofcombat intensity and areusually accompanied byincreased COSR.

Heavy casualtiesnaturally shake Soldiers'confidence in their ownchance of survival.

Loss of a leader or buddyis an emotional shockand threat.

Provide unit updates on status of injured or deceased Soldiers. Provide as manydetails as known about Family support issues and expected recovery of injuredSoldiers. It is critical to inform the unit of both the known and unknown, withupdates as appropriate so rumors and disinformation do not materialize.

Utilize unit peer support system to provide internal decompression of PTE and tohelp prevent or assist with any COSR casualties.

Recognize that grief is a normal response that is expected.

Encourage Soldiers to talk about their grief and loss.

Conduct TEM assessment utilizing UMTs, COSC teams, and BH assets toprovide the appropriate level of supportive services.

Consider event-driven Battlemind psychological debrief if TEM assessmentwarrants.

Consider conducting routine time-driven Battlemind psychological debriefingspreplanned and scheduled throughout the deployed phase of an operation as away of capturing all PTEs throughout the rotation as part of the planning process.

Conduct memorial services.

Promote confidence in the Army Health System and its medical treatmentcapabilities.


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18 March 2009 FM 6-22.5 2-3

Table 2-4. Adjustment and transitional issues (predeployment) risk factors orstressors and preventive measures or leader actions


Lack of information.

Limited time for addressingpersonal issues.

Anxiety and concern regardingupcoming Family separation.

Anxiety and concern regardingFamily functioning after theSoldier has deployed.

Interpersonal relationshipdifficulty.

Children may act out and ormisbehave.

Consider coordinating a UBHNAS to assess the BH of unit prior to enteringthe operational environment. Will also aid in the development and executionof the unit COSC program.

Ensure that unit understands the ROEs and behavior expectations. RemindSoldiers of the intent to return with honor.

Ensure Family readiness is a priority function of unit readiness.

Ensure command involvement and support for Families before deployment.

Articulate readiness goals and the vision for Family readiness.

Establish a functioning, command endorsed and funded FRG Program.

Provide information about the mission, as permitted by operations security(OPSEC).

Effective communication; provide upward, downward, and lateral information.

Single Soldiers without children are often underrecognized as an at-riskpopulation. However, all Soldiers are at risk for developing adjustment andtransitional problems. Utilize the Military OneSource which is able tocoordinate counseling services for Soldiers and Families who needassistance with deployment-related issues at their Web site(http://www.militaryonesource.com ).

Foster a command climate that encourages seeking help for problems.

Utilize Battlemind training system modules.

Conduct additional briefings with small groups of Soldiers.

Allow as much time as possible for Soldiers to address personal and Familyreadiness issues during their predeployment preparation and utilize garrisonUMTs and BH assets to assist the individual, Family, and unit with

predeployment concerns.Discuss the plan for linking Soldiers and Family members to availableresources.

Table 2-5. New Soldier integration risk factors or stressors andpreventive measures or leader actions


Unestablished trust andcohesion.

Replacements might havelimited experience.

New Soldier feeling like anoutsider .

Difficult transition (forpersonal reasons or as theresult of a group dynamic).

Foster unit cohesion and integration of all Soldiers equally to enhance espritde corps and bonding of peer groups.

Impart unit pride and identity.

Ensure that new arrivals are welcomed into the unit, helping them to becomeknown and trusted.

Assign sponsor to new Soldier.

Encourage experienced unit members to teach, coach, and mentor.

Ensure new unit members understand their jobs and are properly trained.

Conduct team-building activities, such as unit physical training or smallgroup activity.


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2-4 FM 6-22.5 18 March 2009

Table 2-6. Perceived threat or actual use of chemical, biological, radiological, and nuclearweapons risk factors or stressors and preventive measures or leader actions


Invisible, pervasive natureof many of these weaponscreates a high degree ofuncertainty and ambiguitywith fertile opportunity forfalse alarms, rumors, andmaladaptive stressreactions.


Prepare Soldiers for chemical, biological, radiological, and nuclear threatcontingencies.

Table 2-7. Home front issues risk factors or stressors and preventive measuresor leader actions


Worrying about what ishappening back home distractsSoldiers from focusing theirpsychological defenses oncombat and operationalstressors. It creates internalconflict over performing theircombat duty and resolving theuncertainties and issues athome.

The home-front problem maybe a negative one—marital or

financial problems, illness,uncertainty, job security (if areserve component or ArmyNational Guard Soldier), or itmay be something positive—newly married or a new baby.

All Soldiers face greaterpotential problems anduncertainties with personalmatters if the military conflict isnot popular at home.

Family readiness is a critical component of unit readiness.

Help Soldiers to prepare themselves and their Families for the disruption andstress associated with deployment.

Encourage Families to maximize their resources and support during allphases of the deployment cycle and utilize the resources that include―

Family readiness groups.

Army Family team building.

Army community services (ACS) and Family support group.

American Red Cross.

Army Emergency Relief.Military OneSource.

Chaplains and BH assets.

Ensure involvement of rear detachment.

Provide regular updates to the home front from the deployed unit. Adopt acomprehensive communication plan that may include a unit newsletter or aunit Web site.

Coordinate with postal support unit for incoming and outgoing mail andpackages.

Provide access to the telephone and computers, when available.

Consult with UMTs, BH teams, and COSC teams.

Encourage Soldiers to self-refer.


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Combat and Operational Stress Prevention, Management, and Control

18 March 2009 FM 6-22.5 2-5

Table 2-8. Loss of confidence, lack of cohesion, and decreased morale risk factors orstressors and preventive measures or leader actions


Insufficient informationand failure of expectedsupport.

Lack of confidence in—

Leaders.

Training.

Unit.

Equipment.

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Army 2009 Field Manual FM 6-22.5

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